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Overview of the
Affordable Care Act
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What is the Affordable Care Act
(ACA)?
• Federal law signed by President Obama on
March 23, 2010 overhauling US healthcare
system.
– Individual Mandate (1/1/14)
– Employer Mandate (1/1/15)
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Employer Mandate
• Employers with 50 or more full-time employees
• Offer affordable healthcare coverage to
employees who work on average at least 30
hours per week (full-time per ACA) with
certain limited exceptions
• Effective date is January 1, 2015
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Measurement Periods
• 12-month period of time used to calculate eligibility
• To determine initial eligibility for 2015 coverage:
– Initial Measurement Period (October 4, 2013 – October 3, 2014)
• Going forward:
– Standard Measurement Period (October 4 – October 3 yearly)
– New variable-hour employees:
• Initial Measurement Period 12 months from 1st of
month following hire date; then eventually transition
to standard measurement period
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Administrative Periods
• The period of time immediately following
the measurement period used to calculate
eligibility and notify employees
– Annually ongoing: October 4 – December 31 (with
open enrollment October 4-31) for January 1 effective
date
– New variable-hour employees: the month following
end of initial measurement period
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Stability Periods
• The 12-month period of time immediately
following the administrative period when
healthcare benefits must be provided to an
eligible employee (if elected)
– Annually ongoing: January 1 – December 31
– New variable-hour employees: 12 month
period starting 1st of month following administrative
period; then transition to standard measurement
period
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Categories of Employees
• Ongoing Employee: an employee who has been
employed with the College for at least one complete
standard measurement period (Oct. 4-Oct. 3)
• New Employee: an employee who has been
employed with the College less than one complete
standard measurement period
– New Full-time Employee: College is certain employee will be
full-time for 12-month period
– New Variable-hour Employee: College cannot reasonably
determine if employee will average 30 hours/week at time of hire
• Variable-hour full-time
• Variable-hour part-time
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Categories of Employees Cont’d.
• Part-time Employee: works less than 30
hours/week
– no healthcare benefits offered
• Seasonal Employee: customary and annual
employment is for a period of 6 months or less and where
work is typically performed at a certain season or period
of the year
– no healthcare benefits offered
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Benefits for Ongoing Employees
• Ongoing Employee: an employee who has been
employed with the College for at least one complete
standard measurement period (Oct. 4-Oct. 3)
– If full-time for the standard measurement period, benefits are
offered in open enrollment (Oct. 4-31) for January 1 effective
date
– Stability period for following calendar year
– Healthcare benefits are maintained for entire stability period
even if hours reduce below 30 hours per work.
– Healthcare benefits will be cancelled upon termination
– Eligibility for next calendar year reviewed again in Oct.
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Benefits for New Employees
• New Full-time Employee: College is certain employee
will be full-time for 12-month period – Offer benefits upon hire
– Employee’s eligibility reviewed again once employed for an entire
standard measurement period (Oct. 4 – Oct. 3)
– Benefits may be cancelled if status changes or employee terminates
before completion of standard measurement period
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Benefits for New Employees
• New Variable-hour Employee: College cannot reasonably determine if
employee will average 30 hours/week at time of hire
– Variable-hour full-time• Reasonable expectation to work 30 hours/week
• Offer benefits at hire and measure
• Benefits may be cancelled if status changes, employee takes extended leave, hours drop
below 30 over a period of time, or employee terminates before completion of initial
measurement period
• If full-time after initial measurement period, continue benefits for 12 month initial stability period
• Employee then rolls onto standard measurement period
– Variable-hour part-time• No reasonable expectation to work 30 hours/week
• Withhold benefits at hire and measure
• If full-time after initial measurement period, offer benefits for 12 months initial stability period
• Employee then rolls onto standard measurement period
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How Will Work Hours be Tracked?
• For hourly temporary employees, HR will review
appointment forms and monitor hours recorded
in Banner
• For salaried temporary employees, HR will use
contracts as provided by managers
• Hours for multiple CofC jobs will be combined
• Hours worked at other State Agencies not
included
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Calculating Hours Worked for
Adjunct Faculty…
• Adjuncts will be credited with 3.0 hours of work
for every 1 hour of course credit taught and
every 1 hour of lab contact taught
• 10 or more credit hours/lab contact hours per
semester equals 30 work hours/week
• Certain exceptions may apply
• Provost’s Office will determine eligibility for
adjuncts and advise HR
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2014 Open Enrollment
• Notices will be sent via campus mail to eligible
temporary employees during the week of Oct. 6th
• Employees can enroll in coverage from Oct. 4-
31 for a January 1 effective date
• If eligible and spouse is a PEBA subscriber,
must have separate coverage
• If an employee feels he/she was not offered
healthcare in error, see appeal process on the
HR Benefits ACA website.
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CofC ACA Website
• http://hr.cofc.edu/benefits/affordable-care-
act.php
• College of Charleston
– Human Resources
• Benefits
– Affordable Care Act
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Affordable Care Act – Full-time
Temporary Employee Insurance
Benefits
Public Employee Benefit Authority
(PEBA) Insurance Benefits
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Important Information
This overview is not meant to serve as a
comprehensive description of the benefits
offered by PEBA Insurance Benefits. For
more detailed information, please read the
2014 Insurance Benefits Guide (IBG) which
can be found on the PEBA Insurance
Benefits Website, www.eip.sc.gov.
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Insurance Available to You
• Health
• Dental
• Vision
• MoneyPlu$ Pretax Group Insurance
Premium Feature
• Health Savings Account
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Who is Eligible for Coverage?
Under the ACA, employees who work an
average of 30 hours or more per week are
considered ACA Full-time and are eligible
for healthcare coverage with certain limited
exceptions.
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Who is Eligible for Coverage?Spouse
• Current spouse or former spouse if coverage is court-ordered
• Spouse employed by PEBA Insurance-covered employer or eligible to be
covered as a funded retiree cannot be covered
Children
• Natural child
• Stepchild
• Adopted child
• Child placed for adoption
• Foster child
• Child for whom employee has legal custody.
• Under age 26
• Coverage may continue beyond age 26 if the child is approved for incapacitation
• If employed with participating employer, your child may enroll as an active
employee or enroll as a dependent child.
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Documentation
• Required for any covered family member
• Must be provided at time of enrollment
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Special Eligibility Situations
• Within 31 days of a special eligibility situation
-Marriage
-Birth, adoption or placement of a child
-Involuntary loss of coverage
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Terminations
• Ineligible Spouse
-Legal separation-must provide documentation
-Divorce (unless court ordered)
-Death
-Gains state insurance coverage
• Ineligible Dependent Children
-Child turns 26, unless approved for incapacitation
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Coordination of Benefits
• Plan that covers person as employee is
primary to plan that covers person as
dependent.
• Children – Plan of parent whose birthday
occurs earliest in year is primary
• Deductibles and coinsurance linked for
married EIP covered members enrolled in
same health.
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COBRA Continuation Coverage
Consolidated Omnibus Budget Reconciliation Act
• COBRA applies to employers that maintain a “group health plan”
• Employee may continue coverage for 18 months
• May continue coverage for 29 months if approved for Social Security disability within the first 18 months of COBRA continuation coverage
• Dependents may continue coverage for 36 months
• You must pay the required monthly premium
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Health Plan Options
• State Health Plan
-Standard Plan or
-Savings Plan
• AMRA TRICARE Supplemental Plan
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Before You Choose a Health Plan
• Read the plan overviews listed in the
Insurance Benefits Guide (IBG)
• Review the exclusions and limitations
listed for each plan
• Determine if your doctor is in the network
• Ask questions – contact PEBA Insurance,
your BA or the plan administrator for
assistance
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Common to Both Standard Plan and
Savings Plan
• Worldwide coverage
• In- and out-of-network benefits
• Pharmacy network
• Online access available –
www.southcarolinablues.com
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Preauthorization
• Refer to Insurance Benefits Guide for
information regarding
– Medi-Call
– National Imaging Associates
– Companion Benefit Alternatives
– Catamaran
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Providers In-Network
• Provider files claims and accepts allowed
amount as payment in full
• Standard Plan members pay deductibles,
copayments and coinsurance
• Savings Plan members pay deductibles
and coinsurance (Savings Plan members
do not pay copayments)
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Providers Out-of-Network
• Member
– May have to file claims
– Can be balance billed
– Pays higher coinsurance
• No benefits paid for out-of-network
prescription drugs in the U.S.
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SHP Limited Preventive Benefits*
• Routine mammography
• Pap test
• Well child care
• Routine colonoscopy
*Refer to IBG for plan guidelines
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SHP - Wellness Incentive Program
• State Health Plan is primary
• At network pharmacies, 12 months free
generic drugs to treat conditions
• Conditions Include:
– Cardiovascular disease
– Congestive heart failure
– Diabetes
Contact BCBSSC for more information
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SHP Standard PlanAdministered by Blue Cross Blue Shield of South Carolina
Standard Plan
-Annual Deductible
$450 individual
$900 family
-Coinsurance In-Network
Plan pays 80%You pay 20%
Out-Network
Plan pays 60%You pay 40%
-Out-of-pocket maximum:
In Network: $2,600 & $5,200
Out Network: $5,200 & $10,400
• $13 per Physician office visit
-Applicable to mental health/substance abuse providers
• $97 outpatient facility services
• $160 emergency room visit (waived if admitted)
Copayments do not apply toward annual deductible or out-of-pocket maximum.
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SHP Standard Plan
Prescription Drugs Copay
31 Days Supply
• $9 Tier 1 Generic
• $39 Tier 2 brand-higher cost alternative
• $65 Tier 3 brand-highest cost alternative
• Copayments apply toward annual Rx $2,500 per person out-of-pocket maximum
• Must use a participating Select RX Network pharmacy
• 90 Days Supply
• $22 Tier 1
• $98 Tier 2
• $163 Tier 3
• Can obtain 90-day supplies at participating pharmacies in the Retail Maintenance Network
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SHP Savings PlanAdministered by Blue Cross/Blue Shield
Health Savings Plan
-Annual Deductible
$3,600 individual
$7,200 family (no embedded deductible)
-Coinsurance In-Network Out-of-Network
Plan pays 80% 60%
You pay 20% 40%
-Out-of-Pocket $2,400 individual $4,800 individual
maximum $4,800 family $9,600 family
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SHP Savings Plan
Prescription Drug Program
• Participating pharmacies and mail order only
• Pay allowable cost until the annual deductible is met.
• Plan pays 80%; you pay 20%.
• Coinsurance maximum is reached, plan will reimburse 100% of allowable cost.
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SHP Savings Plan Added Benefits
• Annual flu shot
• Annual physical that includes specific
services
• Eligibility to contribute to Health Savings
Account (HSA)
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AMRA TRICARE Supplemental PlanAdministered by Selman & Company/ASI
Sponsored by American Military Retirees Association (AMRA)
Features
• Available to retired military personnel under age 65
• Pays secondary after TRICARE
• No deductible, coinsurance or out-of-pocket expenses for covered
services
• Enrollment in AMRA is required
• Reimbursement of prescription drug copayment
• Can Choose any TRICARE-authorized provider
• Coverage is portable
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AMRA TRICARE Supplemental PlanAdministered by Selman & Company/ASI
Sponsored by American Military Retirees Association (AMRA)
Exclusions/Limitations
• No COBRA rights
• No employer contribution per federal
regulations
• Not subject to tobacco surcharge
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Health Insurance Premiums
State Health Plan Standard Plan
Employee: $ 97.68
Emp/Spouse: $253.36
Emp/Child: $143.86
Family: $306.56
State Health Plan Health Savings Plan
Employee: $ 9.70
Emp/Spouse: $77.40
Emp/Child: $ 20.48
Family: $113.00
TRICARE Supplement
Employee: $62.50
Emp/Spouse: $121.50
Emp/Child: $121.50
Family: $162.50
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Tobacco Users Surcharge• $40 per month for subscriber
• $60 per month for subscribers who cover at least one dependent
• Automatically charged unless certify no one uses tobacco
• May certify by completing Certification Regarding Tobacco Use form
• Can be waived if your physician provides a letter stating that it is
unreasonably difficult due to a medical condition for you to stop
using tobacco or it is medically inadvisable for you to attempt to stop
using tobacco.
To avoid the surcharge you must be tobacco free for six months to
certify as non-tobacco user
The SHP offers a free tobacco cessation program
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State Vision PlanInsured and administered by EyeMed Vision Care
Vision Care Services
• Eye exams
• Frames
• Lenses
• Contact lens services and materials
• Diabetic Eye Care benefit
• Discounts on LASIK and PRK vision correction
Providers
• In-network
- No claims to file
- Pay copayment and charges above the plan’s allowance
• Out-of-network
- Pay provider for service
- EyeMed will reimburse you for a portion of expenses for certain services
Locate a provider online – www.eip.sc.gov Click on the “Links” section
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State Vision PlanInsured and administered by EyeMed Vision Care
Eye Exams
• $10 copayment
• Standard contact lens fitting
- No copayment
• Premium contact lens fitting
- 10% discount and
- $55 allowance toward discounted price
Eyeglasses
• Frames every year
- $140 allowance (cannot be combined with any other promotion or discount)
- 20% discount off balance
• Lenses every year
- $10 copayment for single vision, bifocal, trifocal and lenticular plastic lenses
- $45 copayment for standard progressive lenses
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State Vision PlanInsured and administered by EyeMed Vision Care
Contact Lenses*
• Every 12 months
• Conventional lenses
- $130 allowance
- 15% discount off balance
• Disposable lenses
- $130 allowance
*Member may choose either eyeglass lenses or contact lenses, but not both in the same plan year
Monthly Premiums
Employee only $7.00
Employee/Spouse $14.00
Employee/Child(ren) $14.98
Full Family $21.98
Premiums can be paid with pre-tax money under MoneyPlu$ Pre-tax Feature
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Vision Care Program
• No enrollment or premium
• Discount program
• Participating providers only
• $60 for routine eye exam – excludes contact lens
exam
• 20% discount on eyewear except disposable contact
lenses
• You do not have to be enrolled in a health plan
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State Dental Plan
• Self-insured plan
• BlueCross BlueShield of South
Carolina administers claims
• Free to choose any dentist
• No pre-existing condition
exclusions
• $1,000 annual maximum benefit
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State Dental Plan
Class Services Yearly Deductible Percent Covered
I Diagnostic and
Preventive
None 100% of allowed
amount
II Basic $25 80% of allowed
amount
III Prosthodontics $25 50% of allowed
amount
IV Orthodontics None $1,000 lifetime
maximum.
Covered children age
18 and younger only
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Dental Plus
• Supplement to State Dental Plan (SDP)
• Must have same level of coverage as in SDP
• Higher allowed amount for Class I, II, and III services
• Combined maximum benefit of $2,000
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Dental Plus
• Rates
SDP Dental Plus
Employee $0.00 $24.58
Employee/Spouse $7.64 $49.66
Employee/Child $13.72 $57.26
Family $21.34 $74.22
Premiums can be paid with pre-tax money
under MoneyPlu$ Pre-tax Feature
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MoneyPlu$
Pre-tax Premium feature
Premiums are deducted before taxes from your paycheck for:
- State Health Plan
- TRICARE Supplement Plan
- Tobacco Surcharge
- Dental and Dental Plus
- State Vision Plan
There is a $.28 monthly administrative fee
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Health Savings Accounts (HSA)
• Employee must be enrolled in the SHP Savings Plan
• Money deposited into account carries forward from year to year
• Account is portable
• Contributions:
– $3,350 for individuals
– $6,650 for family
– Additional $1,000 catch-up provision for individuals age 55 and older
• Fees
– $1.50 per month to administrative fee to Wageworks (taken pre-taxed from your paycheck)
– $2.00 per month bank fee to Wells Fargo
- Waived with $2,500 balance
- Includes free Visa debit card
- $15 one-time fee for basic order of checks
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MyBenefits
With MyBenefits, you can access your benefits information online anytime:
• See your benefits statement
• Change your contact information
MyBenefits is online at www.eip.sc.gov
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For More Information
Refer to your
“Insurance Benefits Guide”
Visit the PEBA Insurance Benefit’s
website at: www.eip.sc.gov
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Remember
• Open Enrollment is October 4-31, 2014
• Coverage is effective January 1, 2015
• Dependents must meet eligibility requirements
• You are responsible for your benefits
• Nothing is automatic
• Documentation is require if you are covering
dependents
• Social Security numbers and birth dates for your
dependents are needed to avoid delay in processing
your enrollment forms.
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Questions